Kessler RC, Berglund P, Borges G, Nock M, Wang PS. Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 1990-1992 to 2001-2003. JAMA. 2005;293(20):2487–2495. doi:10.1001/jama.293.20.2487
Author Affiliations: Department of Health Care
Policy (Drs Kessler and Wang) and Division of Pharmacoepidemiology and Pharmacoeconomics,
Brigham and Women’s Hospital (Dr Wang), Harvard Medical School, Boston,
Mass; Institute for Social Research, University of Michigan, Ann Arbor (Ms
Berglund); Mexican Institute of Psychiatry, Mexico City, Mexico (Dr Borges);
and Department of Psychology, Harvard University, Cambridge, Mass (Dr Nock).
Context Little is known about trends in suicidal ideation, plans, gestures,
or attempts or about their treatment. Such data are needed to guide and evaluate
policies to reduce suicide-related behaviors.
Objective To analyze nationally representative trend data on suicidal ideation,
plans, gestures, attempts, and their treatment.
Design, Setting, and Participants Data came from the 1990-1992 National Comorbidity Survey and the 2001-2003
National Comorbidity Survey Replication. These surveys asked identical questions
to 9708 people aged 18 to 54 years about the past year’s occurrence
of suicidal ideation, plans, gestures, attempts, and treatment. Trends were
evaluated by using pooled logistic regression analysis. Face-to-face interviews
were administered in the homes of respondents, who were nationally representative
samples of US English-speaking residents.
Main Outcome Measure Self-reports about suicide-related behaviors and treatment in the year
Results No significant changes occurred between 1990-1992 and 2001-2003 in suicidal
ideation (2.8% vs 3.3%; P = .43), plans
(0.7% vs 1.0%; P = .15), gestures (0.3%
vs 0.2%; P = .24), or attempts (0.4%-0.6%; P = .45), whereas conditional prevalence of plans
among ideators increased significantly (from 19.6% to 28.6%; P = .04), and conditional prevalence of gestures among planners
decreased significantly (from 21.4% to 6.4%; P = .003).
Treatment increased dramatically among ideators who made a gesture (40.3%
vs 92.8%) and among ideators who made an attempt (49.6% vs 79.0%).
Conclusions Despite a dramatic increase in treatment, no significant decrease occurred
in suicidal thoughts, plans, gestures, or attempts in the United States during
the 1990s. Continued efforts are needed to increase outreach to untreated
individuals with suicidal ideation before the occurrence of attempts and to
improve treatment effectiveness for such cases.
Suicide is one of the leading causes of death worldwide. As a result,
the World Health Organization1 and the US surgeon
general2 have highlighted the need for more
comprehensive data on the occurrence of suicidal thoughts and attempts, according
to the assumption that such data would be useful for planning national health
care policy, as well as for evaluating efforts to reduce suicide and suicide-related
behaviors. The latter are among the official national health objectives in
the United States.3 The assumption that information
on suicide-related behaviors, including thoughts, plans, gestures, and nonfatal
attempts, is important for understanding completed suicides can be called
into question because only a small fraction of suicide attempters eventually
complete suicide.4 However, suicide attempts
are significant predictors of subsequent completed suicide, as well as important
in their own right as indicators of extreme psychological distress.
Although the National Center for Health Statistics maintains data on
all suicide deaths in the United States according to death certificate records,5 no national data are available on the 1-year prevalence
of trends in suicidal thoughts or attempts. Current estimates of such outcomes
in the United States are drawn from 2 main sources. First, several ongoing
surveillance systems have been established to monitor suicide-related outcomes
among nationally representative samples of individuals in the United States.
The Centers for Disease Control and Prevention maintains a national surveillance
system of nonfatal injuries treated in US hospital emergency departments,6 as well as a surveillance system of health-risk behaviors
among high school students in the United States.7 These
systems provide valuable information, but they are limited because they focus
on narrow groups (attempters who present at hospital emergency departments
and youth who currently attend high school). Second, several epidemiologic
surveys have reported population-based prevalence estimates for suicidal thoughts
and suicide attempts.8- 10 It
is unclear, though, whether these results accurately reflect current prevalence
because of the considerable increase in recent years in the number of people
in the United States who have received treatment for emotional problems.11- 13
Substantial efforts have also been made to develop and implement suicide
prevention and intervention programs during the past decade.14 There
has been a roughly 6% reduction in the period prevalence of suicide in the
United States among people in the sample age range (18-54 years) during this
period, from approximately 14.8 per year per 100 000 population in 1990-1992
to 13.9 per year per 100 000 population in 2000-2002.5 It
is possible that a significant change also occurred in the prevalence of suicide-related
behaviors, including suicidal thoughts, plans, and attempts.
The aim of the current report is to shed some light on this issue by
examining the only nationally representative general-population trend data
available on the 12-month prevalence and treatment of these suicide-related
behaviors. These data are based on the 1990-1992 National Comorbidity Survey
(NCS)15 and the 2001-2003 National Comorbidity
Survey Replication (NCS-R).16
The NCS is a nationally representative household survey of English-speaking
residents aged 15 to 54 years.15 The response
rate was 82.4%, according to the response rate 3 method of the American Association
for Public Opinion Research.17 The latter method
includes the number of completed interviews in the numerator and the number
of originally sampled households, excluding ineligible households (ie, vacant
households and households in which the randomly sampled respondent was found
to be ineligible after contact) in the denominator, with an adjustment for
the estimated proportion of uncontacted households that contained an eligible
respondent. A total of 8098 interviews were completed. The NCS-R is a nationally
representative household survey of respondents aged 18 years and older. The
response rate was 70.9%, with the same method of calculation as in the NCS.
A total of 9282 interviews were completed.
Both surveys used a 2-part internal subsampling scheme in which all
respondents received a part I interview that assessed mental disorders, whereas
100% of part I respondents who met criteria for a disorder and a probability
subsample of part I respondents who did not meet criteria for a disorder were
administered the part II interview. The part II interview assessed risk factors,
treatment, and consequences of mental disorders. Nonrespondent screening data
were used to weight the NCS for nonresponse bias. Other weights adjusted for
differential probabilities of selection and residual discrepancies between
sample and census demographic-geographic distributions. The part II samples
were also weighted for the oversampling of part I respondents with disorders.
More details about NCS and NCS-R samples and weights are presented elsewhere.16,18 Suicidality was assessed in part
I of the NCS and in part II of the NCS-R, whereas most of the correlates examined
here were assessed in part II of both surveys. Data in the overlapping age
range of the 2 surveys (18-54 years) were merged to analyze the trends reported
here by using part II of the NCS (n = 5388) and part II of the NCS-R
(n = 4320).
Introductory letters and study fact brochures were mailed to sample
households to explain the study. Interviewers then visited households to answer
remaining questions before obtaining verbal informed consent and scheduling
interviews. Consent was oral rather than written in the NCS because that was
the standard method of obtaining consent when the survey was designed in the
late 1980s. Oral consent was used in the NCS-R to maintain comparability with
the NCS for trend comparison. Respondents received $25 (NCS) or $50 (NCS-R)
for participation. A subsample of nonrespondents were offered a higher incentive
of $50 (NCS) or $100 (NCS-R) to complete a screening interview. The human
subjects committees of the University of Michigan and of Harvard Medical School
approved these recruitment and consent procedures.
Respondents were asked whether they ever seriously thought about killing
themselves and, if so, whether they had these thoughts in the past 12 months.
Respondents who reported such suicidal ideation were then asked whether they
ever made a plan for committing suicide and, if so, whether they made such
a plan in the past 12 months. Regardless of the answer to the question about
a plan, respondents who reported suicidal ideation were then asked whether
they ever attempted suicide and, if so, whether they made such an attempt
in the past 12 months. Respondents who reported making a 12-month attempt
were then asked to describe the lethality intent of the attempt by indicating
which of the following 3 statements best described their attempt: “I
made a serious attempt to kill myself and it was only luck that I did not
succeed.” “I tried to kill myself, but knew the method was not
foolproof.” “My attempt was a cry for help. I did not intend to
die.” Respondents who endorsed either of the first 2 statements were
considered in the analysis to have made a suicide attempt, whereas respondents
who endorsed the third statement were considered to have made a suicide gesture.
We examined associations of suicide-related behaviors with the mental
disorders assessed in the 2 surveys. These disorders were assessed with the
World Health Organization Composite International Diagnostic Interview (CIDI),
a fully structured diagnostic interview designed to be used by trained lay
interviewers.19 The Diagnostic
and Statistical Manual of Mental Disorders, Revised Third Edition(DSM-III-R) version of CIDI was used in the NCS20 and the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition(DSM-IV) version in the NCS-R.21 We also examined
associations of suicide-related behaviors with 7 sociodemographic variables:
age, sex, race/ethnicity, education, marital status, employment status, and
region of the country. Race/ethnicity was coded into the standard census codes
of non-Hispanic black, non-Hispanic white, Hispanic, and other according to
responses to 2 questions about Hispanic heritage and race. The following prespecified
racial categories were used in the second question: American Indian, Alaskan
Native, Asian, black or African American, Native Hawaiian, Pacific Islander,
white, and other. Race/ethnicity was included in the analysis because of extensive
previous research on the relationship between racial/ethnic minority status
and mental disorder.22 All part II respondents
in both surveys were also asked about 12-month treatment for emotional problems.
Responses were used to distinguish treatment across 5 sectors: psychiatrist,
other mental health specialist (eg, psychologist, social worker in a mental
health specialty setting), general medical practitioner (primary care physician,
nurse); human services professional (religious or spiritual advisor, social
worker in any setting other than a specialty mental health setting); and complementary-alternative
medical treatment (CAM; treatment by a CAM professional, such as a massage
therapist, or participation in a self-help group).
Trends were assessed with pooled logistic regression equations using
the suicidal behaviors as dichotomous outcomes. Predictors included time (NCS-R = 1,
NCS = 0), demographics, and interactions between time and demographics.
Tests for sociodemographic variation in trends were made at P=.001 (ie, .05/28) as an approximate adjustment for the fact that
28 comparisons (7 sociodemographic predictors of 4 outcomes) were being made.
Standard errors were obtained using the Taylor series linearization method23 in the SUDAAN24 software
system. Coefficients were exponentiated to generate odds ratios (ORs) with
95% confidence intervals (CIs). Significance of predictor sets was evaluated
with Wald χ2 tests using design-adjusted coefficient variance-covariance
No statistically significant differences were found between the NCS
and the NCS-R in the 12-month prevalence of any of the 4 outcomes: suicidal
ideation (2.8% vs 3.3%, χ21 = 0.6, P = .44), suicide plans (0.7% vs 1.0%, χ21 = 2.1, P = .15),
suicide gestures (0.3% vs 0.2%, χ21 = 1.4, P = .24), or suicide attempts (0.4% vs 0.6%,
χ21 = 0.6, P = .44)
(Table 1). In subgroup analyses, though,
there was a significant increase in the proportion of ideators who made a
plan (19.6% vs 28.6%, χ21 = 4.4, P = .04) and a significant decrease in the proportion
of planners who made a gesture (21.4% vs 6.4%, χ21 = 10.0, P = .002). This latter decrease (but not the
former increase) is large enough to remain significant even when we use a P = .005-level test (ie, .05/9) as an approximate adjustment
because 9 subsample tests were made to compare the results in Table 1. In comparison, there were no significant differences over
time in the proportion of planners who made an attempt (28.1% vs 32.8%, χ21 = 0.4, P = .53),
the proportion of ideators who had no plan but made a gesture (1.9% vs 3.1%,
χ21 = 0.2, P = .75),
or the proportion of ideators who had no plan but made an attempt (7.3% vs
9.7%, χ21 = 0.1, P = .66).
Rigorous comparison of conditional prevalence estimates of disorders
according to the Diagnostic and Statistical Manual of Mental
Disorders(DSM) is impossible across the surveys
because the diagnostic criteria differ (DSM-III-R in
the NCS and DSM-IV in the NCS-R). In both surveys,
though, the majority of ideators (80%-82%) planners (89%-95%), gesturers (96%-80%),
and attempters (89%-88%) met criteria for 1 or more of the 12-month DSM disorders (Table 2).
Major depression was the most common individual disorder among people with
suicide-related behaviors in both surveys (34%-42% in the NCS and 37% to 51%
in the NCS-R), whereas anxiety disorders were the most common class of disorders
(63%-78% in the NCS and 52%-81% in the NCS-R).
Trends were examined in the associations of 7 sociodemographic variables
with each of the 4 outcomes, even though the overall trends were not significant.
The rationale was that significant changes in subsample trends are possible
even in the presence of no significant change at the population level if an
increase in one segment of the population offsets a decrease in another segment.
All but 1 of these 28 tests failed to exceed the critical value of the test
statistic, whereas inspection of the data in the one case in which the test
was significant suggested that this result was due to an outlier. These results
indicate that suicide-related behaviors not only remained unchanged in the
population as a whole but also in major subgroups of the population defined
by sociodemographic variables.
According to the above result, we were able to pool the data in the
2 samples to examine consistent sociodemographic correlates of suicide-related
behaviors. A global test showed that the sociodemographics were significant
overall in predicting all 4 outcomes (χ218 = 100.5-594.1, P<.001), although the associations were fairly modest
in substantive terms (contingency coefficients, 0.10-0.26) (Table 3). A consistent inverse association existed between age and
all the outcomes, with the highest ORs in the youngest age group (15-24 years;
OR = 2.6-9.8) and the lowest in the oldest age group (45-54 years;
with ORs fixed at 1.0). This association was significant in all 4 outcomes.
Respondents with less than college education had consistently elevated ORs
compared with college graduates (1.8-50.6), although overall education differences
were significant in only 2 of the 4 outcomes. Previously married respondents
had elevated ORs compared with the married respondents (1.5-4.4) significant
in 3 outcomes. Unemployed or disabled respondents had generally elevated ORs
compared with the employed respondents (3.8-4.3) significant in 3 outcomes.
Somewhat weaker ORs were found for being female (1.0-2.9, significant for
1 outcome) and for being a homemaker (1.2-2.9, significant in only 1 outcome).
The never married had elevated ORs for gestures (3.9 and significant) but
decreased ORs for ideation, plans, and attempts (0.4-0.8, significant only
for attempts). Race/ethnicity and region of the country were not significantly
related to any of the outcomes.
Respondents who reported 12-month suicidal ideation were divided into
3 mutually exclusive subgroups defined by the presence of an attempt, a gesture,
or neither. Respondents in each of these 3 subgroups were then distinguished
by whether or not they had a suicide plan, thus creating 6 subgroups. The
proportion of respondents who reported receiving treatment for emotional problems
in the past 12 months increased over time in each of these 6 subgroups, 2
of them significantly so at the .05 level (Table
4). The increases were confined to treatment in the psychiatrist
sector and the general medical sector. No significant increases were found
in the other mental health, human services, or CAM sectors (results available
on request). Although treatment in the mental health specialty sectors (either
psychiatrist or other mental health specialist) remained somewhat more common
than treatment in the general medical sector in 5 of the 6 NCS-R subgroups,
this difference was much more pronounced in the NCS than the NCS-R because
of a greater increase in general medical than mental health specialty treatment
in all subgroups. Even with these increases, sizable minorities with evidence
of suicide-related behaviors (21.0% of attempters, 7.2% of respondents who
made a gesture, and 35.6% of ideators who made neither a gesture nor an attempt)
received no treatment for emotional problems in the past 12 months in the
To explore how the temporal increase in treatment might have influenced
suicide-related behaviors, and particularly the significant decrease in the
prevalence of gestures among ideators, we stratified respondents with suicidal
ideation by treatment and estimated the conditional prevalence of gestures
and attempts. The prevalence of gestures was found not to decrease between
the 2 surveys more among respondents who received treatment than among those
who did not (Table 5). Furthermore,
the prevalence of attempts was found not to increase between the surveys more
among respondents who did not receive treatment than among those who did.
These results should be interpreted with 5 limitations in mind. First,
the outcomes are sufficiently rare that meaningful changes could have occurred
that were not detected as statistically significant with samples of the size
considered here. Also, a number of the ORs in the prediction equation have
wide CIs. Second, suicide-related behaviors are likely to be underreported
because of stigmas that might change and vary at a point in time across sociodemographic
segments of society. Third, although the survey methods were kept as comparable
as possible in the 2 surveys, even subtle differences in interview procedures,
sample nonresponse, or respondent reluctance to admit suicidal thoughts or
behaviors could have led to changes in the internal validity of responses
over time. Fourth, external validity is reduced by the fact that the response
rate was less than perfect, coupled with the fact that the sampling frame
excluded people older than 54 years, individuals living in institutions, the
homeless, and individuals who had completed suicide. Fifth, we did not assess
whether treatments began before or after onset of suicidality, nor did we
assess the adequacy or effectiveness of treatment, which might have changed
With these limitations in mind, the analysis documented 3 noteworthy
results. First, we found no significant changes in the 12-month prevalence
of suicidal ideation, plans, gestures, or attempts, which is consistent with
an earlier analysis that found no evidence of change in the overall 12-month
prevalence of DSM-IV mental disorders in the 2 surveys.25 The lack of trends in suicide-related behaviors does
not follow logically from the failure to find a trend in disorder prevalence
for 2 reasons: a meaningful minority of respondents with suicide-related behaviors
did not meet 12-month criteria for any of the DSM disorders
assessed in the 2 surveys (eg, 18%-20% of ideators and 11%-12% of attempters),
and the remaining respondents with suicidal behaviors had a much higher concentration
of severe and comorbid 12-month DSM disorders than
cases in the general population.
Second, we found that risk of suicide-related behaviors is consistently
elevated in several vulnerable subgroups, including the young, women, individuals
with low education, and individuals lacking stable relationships or employment.
These patterns did not change significantly, which means that the lack of
a significant time trend in the prevalence of suicide-related behaviors in
the total sample does not mask opposite-direction significant trends in major
sociodemographic segments of the population. It also means that the enormous
increase in treatment of emotional problems in the decade between the 2 surveys
did not reduce the disparities in risk of suicide-related behaviors associated
with these disadvantaged social statuses.
Third, we found that treatment increased substantially among people
with suicide-related behaviors, which is consistent with a number of earlier
studies that documented increased treatment of mental health problems throughout
the decade,11- 13 presumably
linked to the introduction of direct-to-consumer marketing of new psychotropic
drugs; new community programs to promote awareness, screening, and help-seeking
for mental disorders; expansion of “carve-out” systems to deliver
mental health services; and new policies to reduce barriers to service use.26- 34
It is not clear how to interpret the finding that suicide-related behaviors
did not decrease when treatment increased dramatically. Completed suicides
decreased by about 6% during this period. The increase in treatment might
have played a part in this trend, although county-level analysis shows no
overall association between amount of treatment, as indicated by per-capita
number of antidepressant prescriptions, and the suicide rate.35 If
increased treatment did play a part in the decrease in the suicide rate, then
why did we not see a comparable decrease in suicide-related behaviors?
One way to begin addressing this question is to recognize that suicide-related
behaviors are distinct from completed suicides, if for no other reason than
their numbers. There are approximately 3000 suicide ideators per 100 000
population and 500 suicide attempters per 100 000 population in the United
States each year compared with only 14 suicide completers per 100 000
population. It is possible that processes affecting the comparatively small
number of suicide completers had no effect on the much larger number of ideators
We cannot rule out the possibility that methodologic factors played
a role in suicide-related behaviors not being less prevalent in the NCS-R
than the NCS. Such factors could include differences between the surveys either
in sample bias or in willingness to admit suicide-related behaviors to interviewers.
Arguing against these possibilities are our adjusting for sample selection
bias with nonresponse adjustment weights and our finding no evidence in responses
to questions about stigma that willingness to admit emotional problems increased
In light of these results, 3 substantive possibilities appear to be
more plausible than methodologic ones in accounting for the finding that suicide-related
behaviors remained unchanged in the NCS and NCS-R when treatment increased
dramatically. One is that the prevalence of suicide-related behaviors would
have increased, were it not for the increase in treatment. A second is that
attempters typically obtained treatment only after making attempts. A third
is that the increase in treatment was of such low intensity or quality that
it had no effect on suicide-related behaviors.
Although all 3 substantive interpretations are equally consistent with
the survey data, other information argues against the possibility that the
increase in treatment prevented an increase that would otherwise have occurred
in suicide-related behaviors. Specifically, randomized controlled trials find
only modest effects of treatment in reducing suicidality, even with optimal
regimens.36- 40 Community
studies of treatment quality consistently find that the majority of patients
currently in treatment for mental disorders receive care that fails to meet
minimal evidence-based guidelines.41- 44 An
added complication raised by the US Food and Drug Administration’s recent
analyses of pediatric antidepressant trials is that the benefit from treatment
in terms of symptom improvement in some patients might be offset by adverse
effects of medications in other patients.45 Taken
together, these results would lead us not to expect substantial effects of
increased treatment on population trends in suicidality.
It is more difficult to determine the relative importance of the other
2 possibilities: that increased treatment either did not reach suicidal people
quickly enough to prevent attempts or that this treatment, when it was delivered
in time, was of such low intensity or quality that it was ineffective in preventing
attempts. Both processes could have been at work, which suggests several important
directions for future investigation. With regard to the timeliness of treatment,
we know that a substantial minority of survey respondents with suicide-related
behaviors received no treatment. In addition, we suspect that at least some
who reported receiving treatment did so only after making a suicide gesture
or attempt. These results mean that efforts are needed to increase access
to and demand for treatment among people with suicidal ideation. The most
serious cases—ideators who make attempts—experienced smaller increases
in treatment throughout the decade than less serious cases. Programs that
expand treatment resources32,46 may
be especially important in addressing this problem, as might initiatives that
encourage timely treatment seeking specifically among people with suicidal
ideation (eg, Substance Abuse and Mental Health Services Administration’s
National Suicide Prevention Lifeline program).47 Because
the dramatic increase in treatment in the last decade failed to reduce sociodemographic
disparities in the suicidal behaviors considered here, programs specifically
targeting high-risk populations are needed. Recent policies and National Institute
of Mental Health initiatives encouraging treatment among traditionally underserved
and high-risk groups may provide useful models.48- 50
Increased treatment, though, will be of little value unless the quality
of treatment is adequate. Efforts are needed to identify optimal interventions
for primary and secondary prevention of suicidality. Although a growing literature
has shed light on the optimal intensity, duration, and follow-up required
to treat mental disorders,51- 56 comparable
data on optimal treatments of suicidal thoughts and behaviors are just beginning
to emerge.57 A recognition is needed that effective
prevention of suicide attempts might require substantially more intensive
treatment than is currently provided to the majority of people in outpatient
treatment for mental disorders. In light of the controversy about the role
of antidepressants in suicidality among adolescents, identifying whether emerging
treatments have the potential to ameliorate suicidality in some individuals
while potentially worsening it in others will be important. The solution is
likely to involve providing intensive monitoring and follow-up, as indicated
in the US Food and Drug Administration’s recent “black box”
warning for all antidepressants.58
Efforts will also be needed to promote the uptake of effective treatments
for suicidality, including those that already exist, as well as any new treatments
that are developed and shown to be effective. Substantial barriers to uptake
of effective interventions continue to exist, including competing clinical
demands and distorted incentives for treating mental disorders and symptoms.31,59- 61 Failure
to disseminate evidence-based treatments widely may, in fact, help explain
why suicidality did not decline in response to the treatment increases during
the 1990s. This means that expansion of disease management programs, treatment
quality-assurance programs, and “report cards” to improve the
quality of care for suicidal patients may all be needed to reduce the burden
of suicidality.62- 66
Corresponding Author: Ronald C. Kessler,
PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood
Ave, Boston, MA 02115 (firstname.lastname@example.org).
Author Contributions: Dr Kessler had full access
to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analysis.
Study concept and design: Kessler, Borges,
Acquisition of data: Kessler.
Analysis and interpretation of data: Kessler,
Berglund, Borges, Nock, Wang.
Drafting of the manuscript: Kessler, Berglund,
Critical revision of the manuscript for important
intellectual content: Kessler, Borges, Nock.
Statistical analysis: Kessler, Berglund, Borges.
Obtained funding: Kessler.
Administrative, technical, or material support:
Study supervision: Kessler, Wang.
Financial Disclosures: Dr Wang has provided
expert testimony in a lawsuit about antidepressants and suicide. No other
authors reported financial disclosures.
Funding/Support: The National Comorbidity Survey
Replication (NCS-R) is supported by the National Institute of Mental Health
(NIMH) (U01-MH60220), with supplemental support from the National Institute
on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration,
the Robert Wood Johnson Foundation (grant 044708), and the John W. Alden Trust.
The NCS-R is carried out in conjunction with the World Health Organization
World Mental Health (WMH) Survey Initiative. We thank the staff of the WMH
Data Collection and Data Analysis Coordination Centres for assistance with
instrumentation, field work, and consultation on data analysis. These activities
were supported by the NIMH (R01 MH070884), the John D. and Catherine T. MacArthur
Foundation, the Pfizer Foundation, the US Public Health Service (R13-MH066849,
R01-MH069864, and R01 DA016558), the Fogarty International Center (FIRCA R01-TW006481),
the Pan American Health Organization, Eli Lilly, Ortho-McNeil Pharmaceutical,
GlaxoSmithKline, and Bristol-Myers Squibb.
Role of the Sponsors: None of the sponsoring
organizations had any role in the collection, management, analysis, and interpretation
of data; or in the preparation, review, and approval of the manuscript.
Collaborating NCS-R Investigators include Ronald
C. Kessler, PhD (principal investigator, Harvard Medical School, Boston, Mass),
Kathleen Merikangas, PhD (coprincipal investigator, NIMH, Bethesda, Md), James
Anthony, PhD (Michigan State University, East Lansing), William Eaton, PhD
(Johns Hopkins University, Baltimore, Md), Meyer Glantz, PhD (NIDA, Bethesda,
Md), Doreen Koretz, PhD (Harvard University, Cambridge, Mass), Jane McLeod,
PhD (Indiana University, Bloomington), Mark Olfson, MD, MPH (New York State
Psychiatric Institute, College of Physicians and Surgeons of Columbia University,
New York City), Harold Pincus, MD (University of Pittsburgh, Pittsburgh, Pa),
Greg Simon, MD, MPH, (Group Health Cooperative, Seattle, Wash), Michael Von
Korff, ScD (Group Health Cooperative, Seattle), Philip Wang, MD, DrPH (Harvard
Medical School, Boston), Kenneth Wells, MD, MPH (University of California,
Los Angeles), Elaine Wethington, PhD (Cornell University, Ithaca, NY), and
Hans-Ulrich Wittchen, PhD (Max Planck Institute of Psychiatry; Technical University
of Dresden, Dresden, Germany).
Disclaimer: The views and opinions expressed
in this article are those of the authors and should not be construed to represent
the views of any of the sponsoring organizations, agencies, or US government.
Additional Information: The full text of all
NCS-R instruments can be found at http://www.hcp.med.harvard.edu/ncs. A complete list of WMH publications can be found at http://www.hcp.med.harvard.edu/wmh.
Acknowledgment: We appreciate the helpful comments
on earlier drafts by Kathleen Merikangas, PhD, and Bedirhan Ustun, MD.